With Congress debating renewal of the Mental Health Parity Act, it can be argued that Sept. 11 added urgency to expanding access to behavioral services.

As a nation, we are dealing with enormous emotional trauma from the events of Sept. 11, 2001, and anxiety over what might happen next. We are talking to each other about sleeplessness, fear, sadness, and depression. We are experiencing the impact of these conditions on our professional lives, our efficiency, and our productivity. Never have we had such an opportunity to understand the effect of mental stress and mental disorders on the workplace and the health of our country.

Studies of other disasters have found that the most vulnerable are those who are most directly affected — including firefighters, police, rescue workers, and medical professionals — but many others less directly touched by a tragedy also are vulnerable. Extraordinary news coverage brought the reality of the Sept. 11 attacks to every living room in the country. A recent study by the Pew Charitable Trust found that 71 percent of Americans said that they have felt depressed by the attacks. Nearly half had trouble concentrating; a third had trouble sleeping. Mental health professionals have warned that the scope and magnitude of the tragedy can be expected to generate unprecedented mental health consequences, distributed far more widely than in any disaster in American history. They also conclude that our mental health system does not have the necessary resources in place to meet the onslaught of psychiatric disorders anticipated.

Toll of mental illness

These predictions add to the conclusions reached previously by national and international experts. In 1999, Surgeon General David Satcher issued an arresting report about the incidence of mental illness, the heavy toll it takes, and the fact that it goes untreated. Satcher's office estimated that about 1 in 5 Americans "experiences a mental disorder" in the course of any year, and that in prosperous nations, mental illness is the second leading cause of disability and premature mortality, after only cardiovascular disease. This year's annual report of the World Health Organization focuses on mental disorders and urges governments to start addressing these problems, which affect some 450 million people. The report, completed before Sept. 11, warns that 1 of every 4 people worldwide will be affected by mental or neurological disorders at some time, but nearly two thirds of people with a known mental disorder never seek professional help.

After the terrorist attacks, community organizations began to offer individual counseling, support groups, and other resources to help people deal with the aftermath. Employers established hot lines and held group sessions; in addition, many companies are encouraging use of employee assistance programs, which offer free confidential, short-term counseling and referrals to workers. It is, however, the accessibility of longer-term therapy for more serious or persistent cases of depression and other mental health conditions that has generated concern. Should the need for such services materialize, it is certain to strain a system that over the past 10 years has been arranged to control access to providers, discourage long-term psychotherapy, and shift more costs for therapy back to members.

Health insurers' unwillingness to pay for mental health care is not news. Five days before the terrorist attacks, Margaret O'Kane, president of the National Committee for Quality Assurance, singled out access to outpatient mental health services in NCQA's annual "State of Managed Care" report, calling it a weak link in the health care system and a "challenge" for the HMO industry.

Rise of managed behavioral health care

Managed care for behavioral health was developed in response to soaring costs for mental health benefits, which a decade ago consumed as much as 12 percent of some employers' health care budgets. Managed behavioral health has since grown into a $4 billion industry, and of the estimated 250 million Americans with health insurance, 158 million are covered by some form of managed mental health program.

The model is not new. For fixed fees, managed behavioral health organizations (MBHOs) contract with insurers and large employers, using their own clinical guidelines and networks of hospitals and therapists to control the kind and amount of care patients receive.

These cost controls and methods of providing oversight have spawned numerous complaints and even allegations of abusive business practices. Lawsuits against MBHOs have alleged that they unlawfully make profits by imposing cost-based restrictive criteria to limit approvals of coverage, providing financial incentives to physicians not to recommend covered services, pressuring reviewers to deny claims, instituting unreasonable approval and appeal requirements to prevent, discourage, and delay policyholders from receiving their coverage rights under the terms of their policies, and arranging to profit directly from undertreatment by assuming the role of an insurance company, not merely a claims processor.

Recently, the Medical Society of New Jersey charged that one specialty managed care organization employed "abusive practices" in its provision of mental health services, and asked the state to investigate the company. Charges against it include that the company misrepresents the services it provides, in addition to the familiar litany of complaints against managed care — administrative hassles, slow or inadequate reimbursement, and fragmented care for patients. The American Medical Association added its support, expressing its concern about "business practices that operate as barriers to needed care for people with mental health problems," adding that "these problems are not isolated to New Jersey."

Another part of the problem is that mental health coverage is not as expansive as insurance coverage of other conditions. Typically, companies that purchase mental health benefits cover only a limited number of sessions with therapists, or make the copayments much higher than for other physician visits. These policies, intended to control costs, routinely restrict access to mental health services by requiring referrals, limiting access to practitioners, and capping the number of therapy sessions they will cover and how much they pay for each. State and federal legislation, typically parity laws and mandatory coverage laws, have failed to deliver open access to mental health care.

Current proposals face opposition

The Mental Health Parity Act expired Sept. 30, 2001, and current attempts in Congress to reauthorize it face stiff opposition from the business community, which is concerned about the effects on health care costs. The 1996 law barred companies from imposing yearly or lifetime spending limits on mental health coverage different from those for physical health, but its failure to address limitations on office visits and hospital days prevents some from receiving the level of service they and their advocates often consider appropriate.

The Senate proposal would expand the definition of what conditions must be covered and would keep insurers from imposing greater limits on inpatient and outpatient visits for mental health care than those established for physical treatment; it also would require identical copayments and deductibles for mental and physical health services.

Nobody believes that expanding mental health services will be easy. Watson Wyatt, the benefits consultant, expects that the events of Sept. 11 will add 1 to 1.5 percent to health care expenses in the Northeastern U.S., due in part to increased referrals to mental health professionals, and because medical costs are significantly higher for people with depression than for those without. Asking purchasers to bear more expense may heighten their opposition, though most seem resigned that some sort of legislation is likely to pass.

While the parity act speaks to the long-term psychological needs arising from the Sept. 11 attacks, unrelated legislation that passed the Senate Health, Education, Labor, and Pensions Committee Oct. 16 should help the short-term need for services. The measure would authorize funding, perhaps as much as $400 million, for services to help those suffering from trauma specifically associated with the events of Sept. 11. One of the bill's sponsors, Tennessee Republican Bill Frist, says the legislation also would improve training for mental health professionals, and integrate behavioral health services in response to the attacks.

Our common experience of Sept. 11 and its aftermath makes this an auspicious time for seeking ways to meet the country's mental health needs. Many believe that the apparent path to ensuring access to care in a system increasingly dominated by managed care is through legislation, but our experience has shown that legislation does not provide a complete solution.

At the same time, employers are experimenting with alternative methods of providing health benefits to employees — such as defined contribution — raising concerns that mental health benefits again will be left out. An effective response must be far-reaching and designed for the long-term. Another coalition must be developed from government, employers, insurers, managed care organizations, community resources, and patients.

No single component is to blame for current needs not being met, and no single entity can improve the system. Each has an important responsibility and role in developing a system that ensures access and provides care for both short-term mild symptoms and serious illness. The immediate responses to the trauma of the attacks came from extraordinary cooperation of community, government, and business groups. It may take the same community solidarity to create an effective system to meet the country's mental health needs.

Madeleine A. Estabrook is a partner at the Boston office of Edwards & Angell, «www.ealaw.com», a full-service national law firm. Estabrook focuses on health care law, advising institutional and individual health care providers, including hospitals, physicians, and subacute and long-term care providers, on legal aspects of their business, including health care regulation and clinical management issues. A graduate of Dartmouth College and the Boston College School of Law, she can be reached at mestabrook@ealaw.com.

Counseling in the aftermath of terror

Heidi J. Dalzell, Ed.M.

The acts of terrorism on Sept. 11 resulted in destruction beyond anything the United States has experienced. Killing and destruction aside, a secondary purpose of terrorism is to establish a sense of psychological helplessness and uncertainty. Though the emotional consequences of these acts may not be fully known for months or years, to the mental health community the tragedy was a call to action, and counseling venues were established throughout the New York area.

Current counseling efforts are crisis-oriented and brief, with such interventions as stress-debriefing groups, single-session bereavement groups, and hot line support. Many companies affected by the disaster are offering therapy services to employees and family members. The Port Authority of New York and New Jersey — which lost 74 employees, including 36 police officers and commanders actively engaged in evacuation and rescue at the time of the attacks — is providing counseling, and encourages workers to take part in group debriefing sessions. Some mental health interventions have been creative, such as the "Cop-2-Cop" hot line set up to help police officers. This initial wave of services, primarily delivered by volunteers, has not relied on managed care funding.

Crisis-counseling sessions should not be confused with therapy per se. They allow survivors to reconstruct events they experienced and to explore reactions to what they have witnessed — the purpose being to mitigate the psychological impact, teach basic stress-management techniques, and identify people at risk for further problems. Most participants would otherwise not seek mental health services; they are well adjusted or are part of a group that historically does not share intimate experiences, such as police officers or firefighters.

Some mental health professionals question the efficacy of crisis-centered approaches in light of our relative inexperience in dealing with an event of this magnitude, and wonder if they may leave managed care organizations to foot an even larger bill for more complicated mental health services down the road. To understand the potential for this, it is helpful to look at a typical traumatic event and human response to traumatic exposure.

Results of traumatic exposure

An acute traumatic event is usually a short but sudden occurrence with a fairly predictable set of consequences. An example that would provoke emotional reactions similar to the World Trade Center tragedy is a school shooting. People who are affected by acute traumas fall into one of two categories: primary victims, who were involved in the event or witnessed it, and secondary victims, who have some relationship to the primary victims. Some of the factors that mediate the development of psychological symptoms are the intensity of the traumatic event, duration of exposure, and frequency of exposure.

Reactions to acute trauma typically have a distinct set of symptoms: intrusive thoughts, sleep disturbance, apprehension, and avoidance behaviors. A Port Authority employee who worked on the 71st floor of the north tower is having a number reactions, including nightmares and difficulty concentrating because of memories of his trip down the stairwell. During his horrifying descent, he saw people from upper floors with terrible burns. Around the 35th floor, he and others trying to escape had to form a single-file line to let a group of firefighters carrying up heavy equipment pass. His most repetitive intrusive thought is to wonder whether any of them got out of the building alive. This memory of seeing the firefighters may well be the most common one experienced by survivors.

Many of these reactions will fade through proper self-care — appropriate rest (especially in the first 24–48 hours after the event), maintaining as normal a schedule as possible, and eating well-balanced meals. Acute post-traumatic stress disorder, with its lingering or more severe symptoms — while by no means simple to treat — is amenable to a relatively brief approach preferred by most managed care organizations. Although early intervention is important, the concern with current efforts is the possibility that they could prove to be little more than Band-Aids, covering psychological wounds but not healing them.

Attention to making sure the wounds are healed is especially important when people are retraumatized daily through news coverage and when victims are unable to establish a sense of personal safety. For primary care physicians, signs that a person's psychological recovery has not progressed may include nausea, headaches, chills, difficulty breathing, poor memory or decision making, and memory or sleep problems, in addition to a number of behavioral effects, such as isolation or addiction. Referral to a qualified mental health professional should be considered when these symptoms do not remit and when they begin to interfere with a patient's family relations, social activities, or work.

While crisis counseling may be helpful to many, there is a very real possibility of delayed onset or chronic stress symptoms, which are more difficult — and costly — to treat. Symptom presentation may not be as clear cut, and may consist of diffuse mood symptoms, intractable depression, or addictive disorders. The trauma of delayed reaction is compounded by patients' false sense that they had "put all this behind" them.

Although the long-range effects of this event are yet to be known, an important part of the response will be attending to the psychological needs of those touched by it. Although these efforts have already begun, an ongoing commitment by managed care organizations and others will be an important part of the work ahead.

Heidi J. Dalzell, Ed.M., is a doctoral candidate interning at the University of Medicine and Dentistry of New Jersey, in Newark. She specializes in providing mental health services to survivors of trauma of all kinds. She can be reached at dalzelhe@cmhc.umdnj.edu.

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